Journal Article > Commentary

Simulation-based education in health care is common, and typically training exercises use artificial and expired medications instead of actual products. This commentary describes how these fake medications can introduce risks when they are accidentally incorporated into active medication inventory and suggests strategies to reduce such confusion in care environments.

Journal Article > Study

This interview study examined the self-perceptions of safety professionals at an energy company, a high reliability industry often used as a model for patient safety. The results reveal that safety professionals often have contradictory roles within an organization, including relational influence versus formal authority and interpersonal skill versus technical knowledge. The findings highlight the challenge of integrating safety professionals into the larger health care enterprise.

Journal Article > Commentary

Establishing errors as learning opportunities is critical for encouraging improvement. This commentary introduces the concept of a growth mindset that views failures as a chance to develop and enhance individual skills. The authors recommend strategies to embed this mindset at the organizational level and they advocate for research to examine the effectiveness of these approaches.

Journal Article > Review

This review spotlights the importance of closing the theory–practice gap for nurses just entering independent practice and discusses methods employed to address the potential for error during this transformative period.

Journal Article > Study

Cognitive bias can lead to diagnostic error. To better understand the prevalence of cognitive error among first-year residents, interns were observed as they handled acute clinical problems during simulation sessions. Researchers found a high prevalence of cognitive error, which did not change over time and adversely affected clinical performance.

Journal Article > Review

Organizational culture, experience, and hierarchy can affect health care workers' ability to speak up about concerns. This concept analysis examines the factors that influence the willingness of student nurses to raise concerns if they see unsafe activities or care omissions. The authors describe ways nurse educators can encourage students to speak up.

This systematic review found little evidence about how to include patient safety skills in clinical supervision. The authors suggest implementing faculty development programs to foster trainees' patient safety skills during clinical rotations, because most learning for postgraduate medical training occurs through supervised experience rather than coursework.

Interruptions pose a significant safety hazard for health care providers performing complex tasks and increase the risk of errors. This commentary describes a simulated training initiative to help prepare nursing students for experiencing and responding to interruptions during medication administration.

Journal Article > Study

Read-backs are widely recommended in order to improve communication of critical clinical information. This simulation study found that anesthesiologists who immediately read back clinical data during simulated emergencies were eight times more likely to retain and use the information appropriately.

Although most patient safety efforts focus on identifying and addressing flawed systems, individual clinicians who cause recurrent problems—either through substandard clinical performance or overtly disruptive behavior—must be addressed as well. This analysis of an Australian national database revealed that just 3% of physicians accounted for nearly half of all complaints filed by patients, and relatively simple characteristics (including physician gender, clinical specialty, and number of prior complaints) predicted the likelihood that an individual clinician would be the subject of future complaints. These data, combined with prior research connecting medical school behavior to the risk of future disciplinary action, provide a means for regulatory authorities to predict problematic behavior by clinicians and point the way toward system-level solutions for problem doctors.

Journal Article > Review

Simulations are increasingly used for teamwork training in scenarios ranging from emergency departments to pediatrics. Simulated operating room (OR) scenarios have also been used for studying the effect of surgical checklists in crises. Despite widespread implementation, previous systematic reviews have raised concerns about variation in type and intensity of simulation programs, as well as the paucity of high-quality studies confirming their effectiveness. This review examined simulation training for integrated multidisciplinary OR teams and found that current simulation studies lack standardization of techniques and measurement methods. While participants in these training programs generally felt that they were realistic and useful, significant barriers were noted, including recruitment, fidelity of surgical models, and costs. The authors suggest that future work focus on how best to overcome these barriers.

An influential 2010 report called for revision of medical education curricula to incorporate patient safety concepts, terming the issue an "unmet need." A recent systematic review found that while safety curricula generally improved trainees' patient safety knowledge, the optimal method for teaching these concepts remains unclear. This randomized trial compared the efficacy of two different types of online education at improving knowledge of the National Patient Safety Goals and incorporating this knowledge into practice. Spaced education, a technique involving repeated interactive online educational encounters spaced over time, was found to be more effective than standard online modules in improving residents' knowledge and adherence to specific procedural safety techniques. As online education becomes more popular in general, this study provides evidence for spaced education as an effective way to communicate patient safety concepts.